tv Chelsea Clinton and Devi Sridhar Discuss Governing Global Health CSPAN March 18, 2017 11:03pm-12:03am EDT
>> good afternoon. one of the exciting things for the day and exciting moment and i have the honor of serving as the dean of columbia university of public health and for all of you here for this exciting afternoon i am thrilled to welcome you. also thrilled not to stand in the way of a great conversation. so i am delighted to introduce our moderator well known to you. michael spare, the chair of the department of health policy and management. michael? [applause] >> hi, everybody. i am the chair of the department of health management and i want to welcome you to the book launch of by devi sridhar and
chelsea clinton. my job today is to introduce chelsea and devi and let them come up and talk for 20-25 minutes, to let you guys ask questions while i have back and forth and i get up toward the end and say it is time to go to a reception and have wine. that is my main job. before i do that, i want to say three quick things about this terrific book. the first thing is as you will hear, i am sure, this book contains four case studies of leading global health organizations around the world. it uses those case studies to provide extraordinary insights into where the world of global health is and where it is going. in that sense, it really adds tremendously to the literature and what we know on the topic. that is number one. number two, the book in an
interesting and unusual way and pretty unique way in those case studies it loo at how those organizations are governed, what their rules on governance are, how they are financed, how transparent they are. it uses these issues to figure out a lens to figure out how impact and influential those organizations are. that is really, again, i think unusual, unique and important. last thing i want to say about this book is in addition to the specific case studies, the book always really examines and considers big important questions in the world of global health and public health more generally. for example, just to give one example, i think, you know, as the authors point out, there is a long history in global health and public health more general
of vertical disease-driven initiatives. at the same time, it is argued by many that sort of horizontal health systems approaches are really perhaps a better way to actually truly improve health. and one of the things the book does is says how will these changing trends in global health and the new kind of organizations coming into the global health deal with the issues of vertical versus horizontal versus health systems. really big questions and the reflection the authors have add to our faknowledge on this. i want to introduce the authors. first devi sridhar, who just got off a plane a few hours ago, is a professor and chair of global public health at the medical
school of the university of edinburg. she directs the global health governance program there. she worked closely, and i think this is important, with ministries of health in low and middle income countries around the world really in an effort to help translate the kind of research she does into action in places that really could use her advice and guidance. she also is a regular commentator on bbc and other numerous outlets. she received her doctorate and masters from oxford. i recently learneded and thought this was interesting, when devi was 18, she became the youngest rohode scholar in history which is an accomplishment.
really grateful and fortunate she is here and co-authored this book with chelsea. devi's co-author is chelsea clinton who we feel is one of us here at colombia. chelsea is a vice president of the clinton foundation. she has her doctorate also from oxford. she has her masters from a school called the health policy of management. she is also a professor, an assi assistant professor here and i would bet there are some people here who in two weeks will be sitting in on class number one och chelsea's class in global health governance. and she has been pretty busy
writing books. chelsea haanother book coming out a year or so ago called "it is your world, get informed, get inspired, get going" i think it just came out in paperback and she will be beginning a book tour on that book pretty soon. so, really, just incredibly grateful to have both chelsea and devi with us today. i want to turn it over to them and introduce and formally welcome chelsea and devi. [applause] >> thank you for that introduction. linda, thank you, and to everyone here at the school for hosting us today. i also want to thank sarah and everyone from oup, our publisher.
i see we have a very young member of the audience. we both have very young children so please don't worry if she feels the need to make her voice heard as well. actually, while we were talking before coming out today, devi and i realized while working on this book we had three children between the two of us. this book grew out of a research we had conductedly independently on the world bank, the world health organization, and a series of conversations we had had with one another and colleagues about gaps we observed in the scholarly literature around global health governance. we could not find a resource that examined the questions michael talked about in his incredibly generous introduction. looking at the four big institutions in global health is judged by resources commanded in order.
the global funds and the world bank and the world health organization and gavi. we wanted a resource that we could reference as well as use in the classes we teach on either side of the atlantic that exami examined these institutions on their governance and accountability and transparency. since we couldn't find it, we decided to write it and indeed a couple years later and three kids later here we have. we thought we would share a little bit of what we discussed in the book and would really welcome your questions. we particularly hope students ask questions. i know that there are indeed students here who will be taking my class later this term and i recognize some of the students i had the privilege of teaching before. so we just are so excited to
have our first book event for our maybe fifth child between the two of us because books are sort of like children here at a school that met, and continues to mean, so much to me. a few reflections from the bock and we hope we can have a conversation. so the four big institutions -- we always find it is surprising to our students that the world bank, for example, funds more global health work around the world than the w joe does every year. we find our students surprised to realize not that long ago the world didn't actually have the global fund or gavi. one of the questions we kind of used to frame much of what we query and attempt to answer throughout the book are what are the differences between the kind
of old institutions or more traditional multilateral traditions like newer partnerships. the global funds and gavi. one, sort of what does the institution do. that is the first question that helps illuminate the differences between the older and newer global health entities. the older institutions tend to have rather broad and ambitious mandates. the attainment at the who the highest attainment. because it is called the world health organization, we tend to think it should be able to kind of do all things for all people to ensure that we each have the chance to live the healthiest
lives possible. the world bank to eliminate and improve life. those sound difference than the founders of the global fund and gavi established. the global funds attracts and disburses additional resources to fight aids, tb and malara. gavi to increase vaines in poor countries. the second difference is who is enfranchised in these institutions. who gets to help curate their agendas and the strategies they employ to achieve those agendas and how they hold themselves accountable and who they partner with or don't. i know these may look silly but when i go to the next slide you
will understand. the world health organization from the world health assembly, kind of the board and the executive board and the entity that overseas the work on a day to day basis, a hundred percent of the memberships are national government and their representatives. the same is true of the world bank. what is very different than these slides that are much more colorful because the membership of the governings bodies of the global fund and gavi are much more diverse comprised of national governments, private companies, and ngo.
we think this slide may seem a bit absurd when it stands alone the juxtaposition is fairly illuminating. is form of governmt and enfranchisement is sething the world has only done a grand experiment with since the new millenium. >> thank you all for welcoming me here. the third question we looked at is who paid for the institutions. if you follow the money you get to the heart of what is happening in. we looked at the who first and the first notable thing is extra budgetary funding has skyrocketed. it is 80% but increased over time. 80% of your budget is earmarked by specific donors for specific causes and 20% is what the
director general can say it is for. norway and sweden saying we will give you $10 million for this. so if you are director general trying to run the organization, how much do you have to say over the budget if 80% is coming from earmarked sources? who are these voluntary contributions? if we take one year, a huge chunk comes from the gates foundation, the u.s., the uk and several others. there is a few key donors that play a large influence. as we saw with chelsea the governance is states but if you look at who pays for it is different. this is ida which is part of how the banks finance their health worth. overtime, it has grown and this
goes to the poorest countries and finances education and public health. you can see there has been growth over time. but who actually has the replenishments? you can see with the donors, u.s., japan, germany, united kingdom and france. if we look at just one year again, perhaps 2012-2014, at the replenishment u.s. 16%, uk 15% and so on. notable the u.s. is the leading institution in terms of financing with the ida. where does the money go? i will come back it this. you can see a lot goes for health systems. the blue. vertical initiatives and problem based initiatives chelsea discussed with gavi and world funds the world bank is notable in that it does spend considerable amounts of health systems and goes against the trend of phoenfocusing on disea.
many people don't realize the trust funds take out a lot. what are trust funds? they are funds donors can set-up for specific prozekts or countries. norway can partner with the u.s. saying we want to do something in maternal health and they come together, pool the money, set-up the governanc and run it through the bank. the financing and governance is separate. they are called trust funds and separate. it is like the backdoor to the bank in a way. how important are these? it is hard to get the details on trust funds but if we plot the who and the world bank you can see there is a lot of money going into these. it is similar to the who earmark funds just a different legality. if we look at global funds, it actually is the u.s., france,
the uk -- 95% coming from bilateral donors. you would hope they would attract new money from private sector, a broader sector like diverse financing. most is bilateral donors and remaining 7.5 from target red which some of you might have heard of. private sector sales and some of the sales go there. the vaccine alliance, bill gates playing a huge part financing 25% and then the uk and then the u.s. what comes out here to summererize is the finance section tells us a large part of the growth and financing, and it is estimated 2/3rd came from the u.s., the uk and the gates foundation. we think of global health as a
global activity with more initiatives and partnerships the base is narrowed down to three. that makes difficult decisions for the director general to be in when you are depending on a few donors for a large part of financing. i will turn it back to chelsea. >> one of the areas our students are increasingly interested in is how much can they know if they are curious about the work of any of these four institutions we focused on. how much can they discover? how transparent is the world bank in what it choses to finance? how transparent is who in who it choses to partner with? how transparent is the global funds in what it choses to provide funding for or not? how transparticipant is gavi on who it choses to work with
vaccines or not and the answer is very not only with respect to the public -- transparency -- but respect to the partners and constituents that make up the governing bodies and institutions themselves. this is important and not only because of increasing norm and expectation all of us share that we should be able to know how our tax dollars are being spent and invested because ultimately the bilateral donations the united states makes or the uk makes are financeed from our respected treasury but also so we know if we want to work with those institutions or partner with those institutions or those interest in academic careers how easy would it be for you to do research on those institutions
or not. so, you kind of see in the slightly two populated graphs on the screen all of the four organizations but for the who has open information policies. what those mean in practice varies. but the global fund and gavi are often cited as real leaders in being transparent, open and accessible by the international aid transparency index, by publish what you fund, and the watchdog organization. and yet the world bank, which has been probably of all of the institutions that we engage with, the most scrutinized for being the hardest to actually scrutinize, has made significant strides in the last six years in being more transparent about
what it funds, where it funds, its contracting, who it partners with and who it doesn't. the who provides very little visibility into what it choses to fund at a granule level, how it makes decisions and we call that out here because we think it is important to note that the institution most expected to set the global health agenda, the only institution that has the ability kind of on this screen to establish real norms in global health, the only institution that has the ability to engage in hard power, to have treaty obligations and those treaty obligations enforced whether we are thinking about the tobacco control convention or other work that we think who should engage with it is the least transparent and the
hardest probably to then hold accountable or to hope to be able to persuade it to engage in moving the world toward greater health for all. so this is something we actually spent a lot of time on in the book. but we will now admittedly pass to debbie for concluding thoughts and open it up for questions. >> great. so the last big issue -- devi -- is how easy is it to reform the institution. how easy can you redirect the secretary to do something you think is better? i won't go into detail because it is different across the four. you will have to read the book. but i will focus on one when is the wh.h.o. because they got a
lot of attention after the ebola crisis and there was a cry to change things. there have been efforts made but it is very difficult to reform the w.h.o. it has been going on since the '80s and it ties into the issues chelsea is discussing with transparency, accountability and trustment it is notable with the w.h.o. that we had an ebola crisis, 10,000 people died, and nobody lost their jobs anywhere in the organization. it just comes back to the issue of accountability, monitoring and making sure people are held responsible and donors delegate because they feel there is an agency able to deliver on those objectives. >> and i would say quickly to
jump in one of the things i think will be really interesting to see with the new director general, whoever emerges from the election in may at the world health assembly, is whether or not that person can reestablish bonds of trust with donors but also recognizing it is not only donors and member states, it is increasingly the global public quality that needs to believe that w.h.o. can and should be establishing norms and leveraging all of it, soft and hard power tools, to help ensure those norms do need to greater health and promotion from more people. that requires an investment from donors and back to devi's point about the fact the director general only has discretion over 20% of her budget, even if she
had responded quicker she would not have had the leverage to deploy human capital or financial resources to the three most heavily affected countries in west africa. it is a bit of a classic chicken and egg challenge and i wish i could think of a more compelling, health based meta metaphor of will donors step up and provide the resources and agency as devi articulated or will w.h.o. have to prove itself more? hopefully if the latter is the case, we won't have another ebola or zika in the interim until w.h.o. or if the world decides they need another institution to deal with emergency preparedness the health system and resilience, we hopefully wot have another ebola to tell us once again why it is so important that the
world be more prepared than historically we have been even in rather recent history. >> i think that is a really important point because now, i guess, as chelsea alluded to, the new director general of w.h.o. will be appointed and some call it the hardest job in the world because of this. your financing is so restricted and you are trying to recruit funding from a strict number of donors but stand up for the world's health. it is a balancing act and difficult job to have and balance all that. just to tie up. why does the global health system look the way it does? that is our concluding chapter. we reflect on why things look the way they do based on the evidence provided before. it the key donors want four key things. tay want to align the objectives with the global agency with
their own objectives. they want to create incentives for performance where you can easily punish or reward through financing or in the global fund in gavi electing the head. we want someone to closely monitor what the global agencies are doing. they want transparency for the public and themselves and they want to have direct voting power. this is important for the non-state actors who are increasingly important. our conclusion, who runs the world and why? you will have to read the book to the get the exact answer what we think but looking forward to the questions we often get are about the global fund and gavi model used for everything? should we have the gavi for child health more broadly. i guess one of the things is it only works if you have very specific and result-based missions where you can say where
the money goes and output. and a lot of health is difficult to do that as you probably learned. finally, what should we do with the world bank and w.h.o. and what roles can they take on. we discussed what they can reform going forward but the key thinis trusting agency. you want countries and you want foundations and other bodies to delegate and give responsibility and give money along with that and trust. to do that, you have to set bench marks and the uk government is doing this through evaluations of agencies according to these criteria. i will turn to chelsea to end. >> another question we often get asked is, you know, is this really the best of times to be living in from a global health perspective and we think the answer to that is pretty simple. depends on where you are living. one statistic that has gotten a lot of attention recently, partly because bill gates spoke
and tweeted about it, is from 2000-2015 annual child deaths declined from 10 million to six million. that is extraordinary. we used to lose six million a children and a million on the day of their birth and a million more in their first week of life. while, if you just think about goodness, there has been a 40% decline isn't that extraordinary? yes. but as mothers of two small children, i don't want to be on the other side of that statistic. we don't think anyone should be. so while we still have enormous work to do we do recognize the world has made real progress. so, to end on a slightly more optimistic note, we conclude our book with the lessons of the global polio eradiation
initiative started in 1988. -- erratication. it is, i think at this moment in time, easy to focus on the fact that we still have polio cases in the year despite 30 years of concerted efforts. more than three billion have been vaccinated against polio, and the work has taken place in more than 130 countries. that is fairly extraordinary. yes, we have work to do. but we think the moral imperative is strong because we have proven what can happen why do focus and mobilize appropriately. so, we are so grateful again to
everyone here. before we open it up to your questions, i want to thank one of our tremendous research assistants who made working on this project a lot of fun and all of the prettiest graphs she did. please give carlina a round of applause. [applause] >> we would welcome any questions about the substance of the become although we will not give it all away. as you heard from devi, we hope you will read it in the entirety. if you have questions about the writing process or other research we are each engaged in we would welcome anything that you may interested in discussing. tonight all raise your hands at
once. yes, in the pink. >> with the amount of money they take, particularly the national health service, what is risi rising -- [inaudible question] >> just to repeat the question. the question is for those of you who could not here why in the uk when resources are so constrained the national celt service would money be spent overseas. i guess there is two reflections. one is if you look at the
proportion that goes to global health out of the country and it is similar to states. we focused on foreign aid and broad. it is tiny compared to what is going into the national health system. in terms of nhs, billions. they talk about 60-70 billion casually and here you are talking about $20 million from all donors. the second thing is i think there is a real commitment in the uk that global health is national health. we all live in an interconnected world and ebola reinforced it. they launched major programs like the global challenge fund that reinforces whatever is happening anywhere in the world will very quickly affect the uk and say for a prosperous world everywhere helps internally.
there is articles coming out why are we spending so much but keep in mind it is a small amount of money in the big scheme of thing and it is well worth it for everyone's best interest wherever you are sitting. >> the same question is often asked here in the united states. the kaiser family foundation does a survey where they ask people what percentage of the u.s. budget do you think goes to foreign aid and last year was 25-26% was the average response. the lowest it has ever been is 11%. we actually spend less than 1% and that is including foreign military assistance. so, if you just carve out what we spend on global health assistance, it is significantly less than 1/10th of 1% of our total budget.
so, although if you look at the majority of the funds that the united states invests in global health around the world, i realize more than $5 billion probably seems like a big number. but compared to a budget of more than $4 trillion it is not a big number. so, i think we don't have the luxury of choosing only one priority when we live in an interconnected and dependent world. i think the united states has a prerogative but also a moral and a security responsibility to leverage both our power and funds in a way. that is why you are seeing such a robust defense from across the political spectrum in the united
states. it is not only a luxury to have the thinking that we can only invest whether it is in health here at home or kind of only invest here at home and not be looking to still invest in helping to create, foster and support greater health agencies and better health outcomes around the world. >> yes? [inaudible question]
[inaudible conversations] >> and you know you have been pushing to have more transparency in the whole ecosystem around development. and find of for livestream, his reflections were partly that there are now broader coalitions across the global health spectrum who are tackling issues collaboratively and whether around transparency in pharmaceutical pricing or other areasism i think we will see
more of this partly because of the sustainability goals encourage that. look at the spg versus the dpg and the explicit multi dimensionality of them and the fact donors are looking to encourage partnerships between groups focused on sustainable developments it is conventionally understood and environmental protection and resilient societies for health system planning and a resilient health system. i think we are going to see just more and more of that. yes? [inaudible question]
process because it was so collaborative. we each took the lead in various areas and iterated a lot. i think we produced a far better book working together than we would have done if i had only been working by myself because it was catalytic and the conception of it was engaging in the research and the drafting and recrafting and re-redrafting. i am so grateful to have had it go off and even more grateful it have worked with devi. >> yeah, and i would reinforce that as well. it was really fun and i use the word fun because you think usually writing a book takes a lot of work but it wasn't solitary. we exchanged drafts daily and chelsea one of the world experts on the global fund and knows a lot about it. more than anyone else i have met. so it is great to work with her
because she could say this is right or not right. she could look at graphs and say this is off immediately. it is really good to have someone always there. in academics we try to do it through sending your articles away and hope it doesn't come back ripped to bits by someone in the universe. but this is constant positive supportive peer review. i could do it with chelsea and i think we both have young kids so a lot of flexibility i can't do today my kid is sick. luckily we lived in different countries so that. find someone you really like, someone you really want to have be your intellectual soul mate. so you don't have too many differences but come together and produce something. it has taken years. >> yes, back to the three kids between the two of us.
>> now so many hands. how about in the blue and white. [inaudible question] >> in writing this book through our research did we find things that surprised us was the question. one of the challenges in answering that question is i became obsessed with the global fund before there was a global fund. i wrote my first masters thesis on the global fund in 2003. so, i can't remember what first surprised me when i kind of first started engaging in a more critically scholarly way with
these types of questions and looking at these institutions. but i will say one of the things that did surprise me is i really did think we would get more reform of the w.h.o. in the aftermath of ebola given the, just overwhelming, cry across the global landscape. even from the review that w.h.o. itself commissioned. so that surprised me. i didn't think we have going to get all the reforms devi and i, for example, had argued for and others advocated but i thought we would get something, if only so that w.h.o. and the director general, could point to and say we did get something done. we have heard these concerns, we have responded to this alarm. so, that surprised me.
>> yeah. yeah, i think maybe two things i will pull out that surprised me. one, is i knew the gates foundation was important. if you work with global health, you know they fund a lot of things and are very vocal about global health but i was surprised how strong they were. th you have to have a clear and clever strategy if you want to align global objectives to what you chose. i know the u.s. and the uk but didn't realize the extent of the gates foundation influence. my passion is for the world bank like hillary's is the global health organization.
hopefully there are positive views on the world bank. one thing that surprised me is the unique funder in health systems. it does seem to go against the trend and doing interesting things with universal health care coverage, think about taxation, how do you raise revenue for health, how do you make surpeople access services it is interesting having this outlier. we don't think about them much in global health because we think of them as a bank. but as a bank, they are dominate in health and doing interesting things. >> and just to add to devi's point about the world bank. the world bank really is the only institution that is trying to not only converge conversations about vertical and horizontal funding but even to
align conversations within horizontal funding. so often there are conversations about health systems strengthing there or the need to invest more in primary health care here or health workforce development here and then over here there are conversations about universal health coverage. with the coupling seemed so ill -- illogical to us. i would argue it seems self evident when we look kroos the developed world when you have the better alignment you tend to get better outcomes. the world bank is really trying to not only exist in the vanguard but to encourage other funders to think along the same lines. and this is particularly important because of what devi
said about the gates foundation. at least thus far, bill gates has made it clear he is not interested in financing the march toward universal health care coverage or resilient health systems across the world. i don't think he deserves tension because of th. he invists millions a year so it is isn't like he is resisting the global health but the contours of this commitment don't include health system strengthening or universal health care coverage. so, it will be interesting to see whether or not a new institution can play the same role that the gates institution did in the advent of gavi either in health system strengthening or ideally marrying the two together in a deliberately and
themselves more see center of decisionmaking and with kind of that being a real meaningful -- that includes agency and not just rhetoric. the global fund arguably are attempted to do that, at least in part. those with developing country governments on their boards, gave with having country-written grant applications, the global fund through eaving countries coordinating mechanism. written grant mechanisms. developing country membership. they also have to have developing country private sector and civil society membership, to facilitate grader coordination the country level on whatever issue or priority the grant is looking to tackle.
and yet, if you read every minute of every global fund board meeting minutes, which i've done and continue to do, and you read all the various committee minutes, which i've done and continue to do, it is clear that while i think the ard memb countries in particular have more ability to influence the agenda, the united states, which provides a third of the global fund's budget, probably still continues to have more ability to influence the agenda. not only through what occurs in the board meetings themselves but the united states actually publishes its view on the board meetings after the board meetings' conclusion. go to the web site and see how the united states feels about
every global fund board meeting over the last, i think now, nine years. debra burkes, who is the u.s. global ambassador is the member of the global fund board from the united states. so, i think that the global fund and gave have gotten further to that. kind of goal, but imperfectly. yet if you really kind of ask the question of who finances global health, global health is defined by kind of what happened in regard to people's health who live in places not like the united states, not our def signatures of global health but often hour global health is treated. so many schools of public health you take a class in global health you's learn about what happens in rwanda and ethiopia
and other countries, but less so about how -- hat w.h.o. influences or fails to positively influence kind of public health for all of us, whether endemic preparedness or tobacco control. the answer to two finances glob health as dined, again in the developing world, really is developing country governments. thes. overwhelmingly. and so i think the question will be going forward, particularly if there is an advent and there's no sign yet there will be but i'm hopeful there will be -- institutional effort to invest in health systems alongside universal health coverage. think that is when we'll really see the pivot you talk about. >> great. so i'll quickly answer the first
question, and the question was, what are the consequences of having three donors basically dominate the funding landscape. so, we highlight -- we have two with major issues and there is an efficiency. so the whole reason the w.h.o. was created and that nations would realize they have to put aside their short-term differences to obtain the benefits of long-term collaboration, and you saw this with health systems and they were neglected and when ebola hit, took them for three months to detect this was ebola because through wasn't the infrastructure and this is what the goble health security alleged was trying to build the -- agenda because none of -- they were focused on aids and tb
and short term priorities and lot the body that was removed from the yearly political cycle of what should be our priority. so it's a major efficiency loss. there is enormative agent here, which is is it right that pry ores are sift by -- priorities sit by three donors? i tell my students would you want your priorities set by some kind of institution far outside which you have access to these services but not access to these services and next year they're cut in half because taxpayers don't want to pay for it. i guess the way to work through it in the world and playing a part with sustainable development and taxation system,
revenue generation, a stronger base of financing and less reliant on external thes thes at of pocket expenditure. i think that's the way you're going to move away from it. it's hard to break away in. if it's taxpayers and say we don't want to do that and we pull back because the government responds to media and public pressure. so that's hope for the fewer. but there is something -- this is why we found -- i want to highlight that three donors dominate not just financing but a myriad other ways. we're tight on time. >> i want to thank everybody here. want to thank chelsea and devi. [applause]
>> i want to -- it's a terrific book. you have to buy it to really get it, and if you want to buy it, it's available the reception we're having in room 401 upstairs. i want to invite everybody actuly if you can exit out of the top door, you're practically there. chelsea and devi will be joining thus for the reception. want to again thank dean and mark, and chelsea's husband and thank everybody for coming and we'll see you the reception. thank you very much. [applause] [inaudible conversations]